Guest Column
| September 3, 2013

Begin Stage 2

By Jamar Ramos

The 2009 American Reinvestment and Recovery Act allocated a significant amount of funds to help strengthen the country's infrastructure. This included measures to incentivize hospitals and other health care facilities to adopt the use of electronic health records (EHRs). The Health Information Technology for Economic and Clinical Health (HITECH) Act outlines standards for the Meaningful Use of EHRs as set out by the Centers for Medicare and Medicaid Services (CMS). Implementing EHRs nationwide may help improve health care by providing access to more accurate information in a quicker, more efficient fashion, as well as giving patients more power over monitoring and taking part in their health care.

EHR adoption is scheduled to be implemented in three stages, and taking part in HITECH is a voluntary action, although Eligible Professionals (EPs) and Eligible Hospitals (EHs) who participate and meet the requirements will be the ones able to earn the incentive payments. Medicaid providers may receive $44,000 over a 5 year span, and Medicare providers will receive about $63,000 over a 6 year period. Although health care providers can choose whether they wish to participate, those who don't join the effort by 2015 will find their Medicare and Medicaid payments reduced by 1 percent for the first two years, and up to 3 percent each year after 2017.

Achieving success in implementing Stage 1 may not mean that hospitals and doctors will be successful at implementing Stage 2. According to the Laura Kreofsky, the Principle Advisor for Impact Advisors, a health care advisory firm, Stage 1 of Meaningful Use "wasn't particularly challenging for many, many organizations" which may put many health care facilities "at a disadvantage for Stage 2." With the growing realization of the difficulties inherent in asking a majority of hospitals, doctors, and care facilities to adopt new technology, many have begun asking that the deadlines for attestation to Stage 2 Meaningful Use be extended. If implementing EHRs correctly is more important than having them installed quickly, the CMS should listen to the voices asking for an extension.

Taking it one Stage at a time
In August of 2012 the final requirements of Stage 2 were announced by the CMS and the Health and Human Services Office of the National Coordinator for Health IT. In Stage 1 hospitals had to meet 15 core objectives and at least 5 out of 10 menu set objectives. Stage 2 requires that EHs meet 17 core objectives and 3 out of 6 menu set objectives, while EPs have to meet 16 core objectives and 3 out of 6 menu set objectives. They can also qualify for exemptions to some of the core objectives.

One of the biggest differences between Stage 1 and Stage 2 is that now EHs and EPs will have to ensure that patients know how to access and use the EHRs being implemented. Jason Fortin, a senior advisor for Impact Advisors, said that hospitals and other health care providers "have to be able to identify patients who could benefit from [EHRs] and use [them] regularly." The question becomes, however, "[w]ho's responsible for that? When does that occur in a visit" to the doctor's office?

Other new responsibilities include prescribing drugs, reporting lab results, and summarizing patient care through electronic means. EPs and EHs will also have to choose which clinical quality measures (CQMs) they report on. These CQMs help measure the ability of a health provider to deliver quality care to their patients. Some of the areas measured include patient engagements, clinical processes, patient safety, health outcomes, efficient use of health care resources, and care coordination. CQM's must also be submitted electronically, which means that health care professionals need to be careful about which EHR they use, as choosing certain CQMs to report on may necessitate a massive upgrade to their existing system.

A large number of health care providers, according to Fortin, deferred many of the optional Stage 1 goals, with "something like 90 percent of hospitals and maybe 85 percent of EPs [deferring] the measure for transitions of care." That optional measure is no longer optional in Stage 2, and health care professionals now have to deal with it, along with many other requirements that can no longer defer.

Realities of implementation
With all the confusion, and all the requirements of Stage 2 Meaningful Use, many are asking that the time frame to prove out their compliance with the stated goals be extended. Currently the attestation period is supposed to last 12 months, but places like the College of Healthcare Information Management Executives, the Healthcare Information and Management Systems Society (HIMSS), and the American Academy of Family Physicians (AAFP) are asking for that timeframe to be extended to 18 months.

Both HIMSS and AAFP have written letters to the CMS asking for the extension on the first attestation period. In the HIMSS letter, they argue that, while they feel that the requirements are necessary in order to provide the best care to patients, "eligible professionals, eligible hospitals and vendors are increasingly citing timeline and certification challenges in preparation for Meaningful Use Stage 2."

HIMSS has gathered a lot of analytical data in order to back up its claims, reporting that 68 percent of EHs have made the move to buy EHRs but are waiting on upgrades and don't know if their systems will be operational, or that they will have the correct version, by the time they need to start meeting the requirements. The American Hospital Association (AHA) has agreed with the assertions made by HIMSS, and gave testimony to the Senate Committee on Finance in July. The AHA said that hospitals are making huge strides to invest in EHR technology and hire the necessary support staff to make sure it is implemented in the proper fashion.

The letter that the AAFP sent to the CMS mirrors the concerns that HIMSS made known. In particular it points out that all of the requirements necessary to qualify for the incentive payments "may derail health information technology adoption" and that could lead to not being able to provide "better care for patients, better health for communities and lower costs through improvements to the health care system." None of these agencies is asking that the start of Stage 2 be delayed, just that the first period of attestation extend for an extra 6 months in order to make sure everyone involved is able to safely and securely implement EHRs and to ensure they work properly.

Done quickly, or done correctly?According to an article by Brian Eastwood, early adoption of EHRs wasn't very successful. From 2008 through 2012, hospitals that used EHRs with advanced functionality rose from 9 percent to 44 percent. For physician offices, it went from 17 percent to 40 percent. Those are great numbers, but the speed with which they implemented the new technology has brought about frustrations, as studies show that 23 percent of health care professionals want to switch their EHR systems, and 39 percent of clinicians would not recommend their EHR to a colleague. While the newness of the technology may be part of the reason for the dissatisfaction, as there could be problems that need to be fixed, part of it may also be the fact that EPs and EHs need to quickly install, upgrade, and learn how to use EHR's so that they can earn the incentive payments. Extending the backend deadline for Stage 2 attestation may allow for doctors, nurses, and other care professionals to become more comfortable with the technology, or to take health information technology courses to supplement their knowledge.

Providing doctors and hospitals the latest in health care technology to lessen the amount of paperwork they need to fill out can make them more efficient in the long-term. It can also help with transitioning a patient from one doctor to the next, as files, test results, and other pertinent information can be passed from one office to the next with relative ease. Patients and their care givers can also access this information, giving them more involvement in their health. Giving EHs and EPs a few extra months so that they can make sure they have enough time to learn what they need to operate their EHR systems might enable them to avoid some of the pitfalls that can occur when using new technology.

About the AuthorJamar Ramos has been writing poetry and fiction for many years, and earned his bachelor's degree in Creative Writing from San Francisco State University. For the last three years, Mr. Ramos switched to producing blog posts for CBSSports.com and writing professionally as an independent contributor for a number of Internet sites. His creative works have been featured in The Bohemian and The San Matean. He now contributes articles for OnlineDegrees.com, OnlineColleges.com, and AlliedHealthWorld.com.